COURSE PRE-APPROVAL REQUEST
Step 3: Tuition Reimbursement
To be completed BEFORE semester begins
Name:
Department: Title:
Name of College orUniversity:
Semester course(s) to be taken:
Course Title(s) and Catalog Number Number of Semester Hours
1.
2.
3.
Approximate Cost: Tuition $ Books $
Did you receive funds from any other source for payment of tuition/textbooks? __Yes __No
Employees receiving tuition assistance from a source that does not require repayment (Veteran’s benefits, grants,
scholarships, etc.) are required to submit reimbursement requests for the balance of the tuition not covered by the
alternate source. The City of Stephenville has the right to audit the employee’s educational and financial records that
may be contained in the employee’s records at the institution attended. I agree that any right I may have pursuant to
the Family Education Rights and Privacy Act of 1974, or any similar act, is waived by acceptance of tuition
reimbursement. I understand that the penalty for fraudulently seeking a tuition reimbursement benefit may include
corrective action. By signing this application, I acknowledge that I am familiar with the requirements for tuition
reimbursement pursuant to the City’s personnel policy and agree to abide by those requirements.
Employee Signature Date
HUMAN RESOURCES DEPARTMENT
Human Resource Director Signature Date
Appendix E
Form 8
NOTE: To be eligible for tuition and book reimbursement, the employee must have an approved Application for
Degree Plan Approval on file with the HR Department. This request form must be completed by the employee and
submitted to the Human Resources Director prior to taking a course.
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
